Inspection·September 19, 2019

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of late meal trays. They revealed they had brought up the concern previously in Resident Council meetings, and the concern had not been resolved. They revealed they wait for extended periods of time for their trays as they have no idea when the trays will arrive. Resident #103 revealed there had been someday's she had not received her lunch tray until 2:30 P.M. Resident #80, who was the Resident Council President, revealed she did not feel the facility provided the Resident Council with an effective action plan of how they were addressing the late meal trays as the concern continued. Interview on 09/17/19 at 3:50 P.M. with Activities Director #602 verified the residents had voiced complaints at a few of the Resident Council meetings regarding their meal trays being late. He revealed Dietitian #442 and/ or Dietary Manager #443 had been present at the meetings and were aware of the continued complaints. Interview on 09/18/19 at 5:50 P.M. with Licensed Practical Nurse (LPN) #600 revealed there had been a concern with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their glucometer checks and insulin sliding scale coverage at 4:00 P.M. She revealed she administered Resident #56, #92 and #110 their insulin sliding scale coverage at approximately 4:00 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. The dinner trays arrived on the B unit at 5:56 P.M. Interview on 09/19/19 at 10:29 A.M. with Dietitian #443 revealed he had been aware of the resident complaints regarding their meal trays being late. He revealed they had been having issues with late meals because of staffing and dietary turnover being the contributing factors. He revealed they had hired and were in the continued process of training. He was not aware of any other action plan currently regarding the concern of late meal trays. Interview on 09/19/19 at 10:45 A.M. with Dietary Manager #443 revealed she was aware of the residents' concerns of late meal trays. She verified she was aware the residents voiced their concern at the June 2019 and August 2019 Resident Council meetings regarding late meal trays, and it remained a concern of the residents. She revealed she was attempting to prep more at night, hire more dietary staff, and train the staff hired. She verified there was a few days lunch trays were not served until after 2:00 P.M. Review of facility policy titled, Resident Council dated 10/18/01 revealed the Resident Council was intended to promote resident interest and provide a forum for residents to voice their opinions, concerns, suggestions for change in day to day operation of the facility. The council was to meet monthly to discuss issues and seek resolution of concerns of residents. The facility would investigate Resident Council concerns as the activity director or designee would submit the expressed concern to the appropriate facility department or administrator on a Resident Council concern form. The facility would, before the next meeting, return the form and an action plan of how they will resolve the concern. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide quarterly care conferences for Resident #122 and Resident #144 according to the regulatory requirements. This affected two residents (Resident #122 and #144) of three residents reviewed for care planning. The facility census was 170. Findings included: 1. Review of the medical record for Resident #122 revealed an admission date of 10/21/80 with diagnoses including cerebral palsy, quadriplegia and profound intellectual disability. The resident's mother was listed as her legal guardian. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was totally dependent for activities of daily living, was not comatose, had adequate hearing, impaired vision and daily physical behaviors directed towards herself. In the section regarding the daily preferences for everyday living, the staff gave input but did not include her guardian. The record did not contain any evidence that interdisciplinary plan of care meetings were held to include a state tested nursing assistant (STNA) familiar with her care or to include the guardian on the days staff knew she regularly visited the facility. Observations were conducted of Resident #122 on 09/16/19 at 11:11 A.M., 09/16/19 at 3:30 P.M., 09/17/19 at 9:37 A.M., 09/18/19 at 1:33 P.M. and 6:01 P.M. and 09/19/19 at 10:10 A.M. Each time the resident was dressed in a hospital gown, appeared to be visually impaired and unable to move herself in her bed. During verbal stimulation she would turn her head and make unintelligible noises. She had a tube feeding and did not eat by mouth. She had a room mate who was alert and disoriented to person, place and time and did not interact with Resident #122. Resident #122 was never seen out of her room throughout the four day survey. Interview was conducted on 09/18/19 at 12:56 P.M. with the Social Services Director (SSD) #603 who verified she had seen the guardian visiting Resident #122 on Sundays and a few times a week in the evenings. She said she had not made any attempts to schedule plan of care meetings when the guardian routinely visited in the facility on Sundays or in the evenings. SSD #603 revealed she had worked at the facility for about a year, and it was her understanding Resident #122 should not leave her room. When asked if she had ever tried to ask Resident #122's guardian if she would consider permitting her to leave the room for social time, SSD #603 said no. SSD #603 added the resident was discussed at weekly risk management meetings, but those meetings did not include a STNA familiar with her care nor was it a plan of care meeting specific to that resident. 2. Review of medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, dysphagia, hypertension, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of care plan dated 01/31/19 revealed Resident #140 planned to be discharged by the end of October 2019, and he needed a new place to live. Interventions included to allow resident choice related to daily care, and the resident was to be offered opportunity to verbalize feeling related to placement. Review of facility form titled, Plan of Care Review Summary dated 03/21/19 revealed SSD #603, Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #605 and Physician #950 by telephone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm participated in reviewing Resident #140's plan of care. The notes of the care conference revealed Physician #950 restricted leave of absence until care conference for safety as Resident #140's pattern of poor decisions while on leave of absence could potentially cause harm to self and others. The resident agreed to make better decisions and his leave of absence restrictions were lifted. There was no documentation the resident or resident representative attended the meeting. Residents Affected - Few Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #140's Brief Interview of Mental Status (BIMS) score was a 13, indicating he was cognitively intact. He required extensive assist of two persons with bed mobility and was totally dependent of two persons with transfers. Interview on 09/16/19 at 3:18 P.M. with Resident #140 and his wife revealed they did not feel the facility was assisting or keeping them informed regarding Resident #140's discharge planning, and they revealed they had not been invited or had participated in any care plan meetings since his admission. Resident #140's wife revealed she comes daily to the facility to visit her husband. They revealed they had not been informed on admission regarding care conferences and had not received a letter or schedule when Resident #140's care conferences were. Interview on 09/19/19 at 09:37 A.M. with SSD #603 and Social Service Designee #604 revealed they send out a letter inviting family quarterly and for a significant change. They revealed if the family returned the call, they set up a care conference with the family. They revealed if the family did not call back, they did not have a care conference. They revealed they only had documentation for Resident #140 having a care conference on 03/21/19 but verified it was not marked on the form if the resident or surrogate was invited, attended, or if they declined. They verified they did not have any other documentation in the medical record regarding any other care conferences held for Resident #140. They verified they did not document the reasons, including the steps the facility took to include the resident and/ or the resident representative in care planning in the medical record. Review of facility policy titled, Resident/ Resident Representative Care Conferences dated 08/08/06 revealed the facility was to provide the resident and/ or resident representative the opportunity to participate in the resident's plan of care. The facility, on admission, was to inform the resident and/ or representative of the facilities' care conference protocols. They were to be offered an initial care conference meeting and informed of a projected schedule for quarterly care conferences for the year. The agenda for care conference meetings included but not limited to customer service queries, discharge planning, advance care planning directives, realistic goal setting and communication structure. The facility would send out routine letters to residents and residents representatives reminding them of the availability of the care conference meeting. If the participation of a resident and/ or resident representative in a care conference was determined not practicable an explanation would be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to provide adequate activities for Resident #122. This affected one of two residents being reviewed for activities. The facility census was 170. Residents Affected - Few Findings include: Review of the medical record for Resident #122 revealed an admission date of 10/21/80 with diagnoses including cerebral palsy, quadriplegia and profound intellectual disability. The resident's mother was listed as her legal guardian. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was totally dependent for activities of daily living, was not comatose, had adequate hearing, impaired vision and daily physical behaviors directed towards herself. In the section regarding the daily preferences for everyday living, the staff gave input but did not include her guardian. The plan of care with a date initiated of 06/10/11 and authored by Activity Director (AD) #602 indicated Resident #122 had a guardian who did not want Resident #122 to leave her room for any activities. Observations were conducted of Resident #122 on 09/16/19 at 11:11 A.M., 09/16/19 at 3:30 P.M., 09/17/19 at 9:37 A.M., 09/18/19 at 1:33 P.M. and 6:01 P.M. and 09/19/19 at 10:10 A.M. Each time the resident was dressed in a hospital gown. During verbal stimulation she would turn her head and make unintelligible noises. She had a room mate who was alert but disoriented to person, place and time. Resident #122 was never seen out of her room throughout the four day survey. She had a tube feeding and did not eat by mouth. There was a radio and reading materials in her room but no tactile or aroma sensory objects in her room. Interviews were conducted on 09/18/19 from 11:15 A.M. to 11:33 A.M. with AD #602, Activity Aide (AA) #607 and AA #608 regarding Resident #122's participation in activities. AD #602 revealed Resident #122 only left her room to be showered twice a week and had room visits because her guardian/mother did not want the resident to leave her room. AD #602 explained he had never came out and asked the guardian why she could not leave her room because he had worked with her in the past, and he believed the guardian had a stigma about Resident #122 being seen in public and people seeing her due to her condition. AA #607 added when pets visit AA #607 would take the pet into Resident #122 and put her hands on the fur. Resident #122 would respond by making squealing noises like she enjoyed it. AA #608 shared the document Monthly 1:1 Log dated August 2019 for Resident #122 and verified she and AA #607 had provided reading magazines, singing songs and playing music to her 16 times for 15 minutes each and rubbed lotion on her hands three times for 15 minutes each during the month of August 2019. AD #602 said they did not provide any evening activities after 3:00 P.M. to Resident #122, and there had not been any pet visits for several months. Interview was conducted on 09/18/19 at 1:33 P.M. in Resident #122's room with Licensed Practical Nurse (LPN) #606 who revealed she had been Resident #122's nurse for several years. She said a typical day for Resident #122 was to be dressed in an institutional gown, spend her day in her room and staff would turn the radio on for her to keep her company. LPN #122 said staff do not take her out of her room except for a shower because that was the guardian's wishes to her knowledge. LPN #122 verified the staff only dressed her in an institutional gown and Resident #122 would cry out through the day randomly and scratch at herself for no known reason. LPN #122 verified the only activity materials in the room were a radio and reading materials, and Resident #122 was dependent on staff for all of her activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview was conducted on 09/18/19 at 12:56 P.M. with the Social Services Director (SSD) #603 who revealed she had worked at the facility for about a year, and it was her understanding Resident #122 should not leave her room. When asked if she had ever tried to ask Resident #122's guardian if she would consider permitting her to leave the room for social time. SSD #603 said no. SSD #603 added Resident #122's guardian visited every Sunday and had seen her on Sundays when she worked on the weekend but had not thought to discuss with her liberalizing Resident #122's social opportunities through different activity participation. Event ID: Facility ID: 365286 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not provide a timely weight assessment and/or nutritional interventions for Resident #71 and Resident #119. This affected two (Resident #71 and Resident #119) of six residents reviewed for nutrition. The facility census was 170. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #119 revealed an admission date of 02/18/13. Diagnoses included cerebral infarction, dysphagia, hemiplegia and hemiparesis, anorexia nervosa, vascular dementia and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/10/19, revealed the resident had impaired cognition. The resident had delusions and physical behavior directed at others. Resident #119 required limited assistance for eating. The resident was on hospice. Review of physician orders for 09/2019 identified orders for a regular diet, pureed texture, nectar thick liquids. Review of the dietary progress note dated 08/07/19 at 9:04 A.M. revealed Resident #119 was receiving hospice services. On 07/04/19, the resident weighed 142.2 pounds and had a Body Mass Index (BMI) of 19.8 indicating underweight status for age and a height of 71 inches. There were no significant weight changes at one, three or six months; however, a gradual weight loss of 11.4 pounds was noted. The resident received assistance with feeding in the dining room and consumed 25 to 75 percent of meals on the pureed diet with nectar thickened liquids. Meal intakes were not meeting estimated daily nutrient needs. The resident was at high risk for nutritional decline per the nutrition risk tool. No new recommendations were made. The plan was to continue with current diet regimen. Review of the dietary progress note dated 09/06/19 at 10:20 A.M. revealed Resident #119 was no longer receiving hospice services. No new weight had been obtained from the previous dietary progress note. The resident was assisted with feeding and was consuming 25 to 100 percent of meals on the pureed diet with nectar thickened liquids and tolerating well. The plan was to continue with the current diet regimen. Review of supplement documentation revealed no supplements were provided. Review of weights revealed on 09/10/19 Resident #119 weighed 138 pounds. On 06/21/19, the resident weighed 141.8 pounds. On 01/08/19, the resident weighed 153.6 pounds. Resident #119 had a weight loss of 2.75 percent in three months, 4.35 percent in six months and 11.3 percent in eight months. Interviews on 09/18/19 at 10:41 A.M. Registered Dietetic Technician (RDT) #442 verified Resident #119 was not receiving a supplement, and no interventions had been made even though the dietary progress notes indicated meal intakes were not meeting estimated daily nutrient needs, the resident was at high risk for nutritional decline per the nutrition risk tool, and there had been a gradual weight loss. 2. Record review was conducted for Resident #71 who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and trouble swallowing (oropharyngeal dysphagia). The MDS 3.0 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment dated [DATE] indicated he was cognitively intact and required set up assistance by staff for meals. The Plan of Care with an initial date of 12/24/15 indicated he was at nutritional risk due to Parkinson's disease and swallowing problems. The interventions included monitoring weights and notifying the physician of any significant weight changes. The weights documented in the record were as followed: 02/12/19 - 162.0 pounds, 03/26/19 - 158.0 pounds, 04/16/19 - 155.8 pounds, 05/04/19 - 153.0 pounds, 06/10/19 -152.0 pounds, 07/04/19 - 151.0 pounds, 08/20/19 - 145.8 pounds and 09/07/19 143.4 pounds for a 10.0 percent significant weight loss from 02/12/19 to 08/20/19. On 12/19/15, a physician's order for a regular diet was written, and on 06/18/19 a physician order was written to encourage 240 milliliters (ml) of fluid every shift due to dehydration risk. Record review was conducted of the Dietary Assessment Narratives and Nutrition Assessments authored by RDT #442 from 04/01/19 to 07/19/19. The Dietary Assessment Narrative from 04/01/19 revealed staff assisted Resident #71 with feeding due to tremors from Parkinson's disease, he was at no risk for altered hydration status, meal intakes were meeting his needs. The goal was to maintain his weight within one to three pounds of 158 pounds and continue his regular diet. The next entry by RDT #442 was another Dietary Assessment Narrative from 07/11/19 noting a gradual weight loss of 13.4 pounds over six months with a current body weight of 151 pounds. The goal was to maintain his weight within one to three pounds of 151 pounds, and RDT #442 had no new recommendations. The Dietary Narrative on 07/18/19 by RDT #442 revealed Resident #71 was placed on dehydration alert protocol on 07/18/19, and RDT#442 wrote he would continue to monitor the resident. The were no further entries by RDT #442 addressing the dehydration risk or the documented weight of 145.8 pounds with a significant weight change on 08/20/19. An interview and observation was conducted on 09/17/19 at 2:21 P.M. with Resident #71 in his room. He was left side lying across his bed with his lunch tray sitting on his bed side table next to his bed. When asked if he was having any problems eating, he reported his right hand (dominant hand) was hard to close, and that made it difficult to hold the utensils on his meal tray. He demonstrated trying to close his hand, and his fingers were not able to close enough to touch his palm. Resident #71 said he preferred to eat in his room and had just consumed all of his lunch. He appeared thin for his frame, spoke in a soft voice with somewhat garbled speech but was able to get his meaning and points across to the listener. An interview was conducted on 09/18/19 at 11:55 A.M. with RDT #442 with the Director of Nursing (DON) present during the interview. RDT #442 stated he knew the resident was having what he referred to as an insidious weight loss most likely related to his Parkinson's disease. RDT #442 verified he had not addressed Resident #71's significant weight change, did not put any interventions in place to address the weight change nor was the physician notified of the weight change. RDT #442 verified Resident #71 had lost an additional 2.4 pounds from 08/20/19 to 09/07/19, and he had not made any entries in the medical record since 07/18/19. Record review was conducted of the facility document titled Weight Change Protocol, dated 07/01/04. The document stated resident weights would be reviewed weekly to identify those residents who were experiencing weight changes and appropriate interventions would be put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have accurate pain assessments for Resident #48. This affected one resident (Resident #48) of one resident reviewed for pain. The facility census was 170. Residents Affected - Few Findings include: Record review for Resident #48 revealed an admission date of 12/13/16 and diagnoses that included low back pain, hypertension, chronic obstructive pulmonary disease and diabetes. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #48 revealed he was cognitively intact. He required limited assist of one person with bed mobility and extensive assist of one person with transfers. He had pain present with a pain intensity of a three out of ten and was on a pain medication regimen. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 08/08/19 completed by Licensed Practical Nurse (LPN) #900 revealed Resident #48's pain was assessed for the last five days (from 08/03/19 to 08/08/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of August 2019 Medication Administration Record (MAR) for Resident #48 revealed he had received Percocet tablet 5-325 milligrams (mg) (opioid pain medication) one tablet by mouth every 24 hours as needed for severe pain on 08/03/19 at 6:41 P.M. as his pain was a four out of ten, on 08/04/19 at 6:41 P.M. as his pain was a seven out of ten, on 08/06/19 at 5:17 P.M. as his pain was a five out of ten, and on 08/07/19 at 6:37 P.M. his pain was a four out of ten. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 08/16/19 completed by LPN #900 revealed Resident #48's pain was assessed for the last five days (from 08/11/19 to 08/16/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of August 2019 MAR for Resident #48 revealed he had received Percocet tablet 5-325 milligrams (mg) one tablet by mouth every 24 hours as needed for severe pain on 08/11/19 at 1:01 P.M. as his pain was a eight out of ten, on 08/12/19 at 4:15 P.M. as his pain was a eight out of ten, on 08/14/19 at 1:13 P.M. as his pain was a six out of ten, and on 08/15/19 at 3:13 P.M. his pain was a three out of ten. Review of care plan last reviewed 08/28/19 revealed Resident #48 had pain related to low back pain, foot drop pain, discomfort associated with activities of daily living and neuropathic pain. Interventions included one on one sessions to allow resident to express his feelings, provide rest periods, administer pain medication as per physician and monitor effectiveness, acknowledge presence of pain and discomfort and listen to his concerns, and document complaints and non-verbal signs of pain. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 09/06/19 completed by LPN #900 revealed Resident #48's pain was assessed for the last five days (from 09/01/19 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/06/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of September 2019 MAR for Resident #48 revealed he had received Percocet tablet 5-325 milligrams (mg) one tablet by mouth every 24 hours as needed for severe pain on 09/01/19 at 4:33 P.M. as his pain was a four out of ten, on 09/02/19 at 5:47 P.M. as his pain was a seven out of ten, and on 09/04/19 at 3:49 P.M. as his pain was a six out of ten. Interview and observation on 09/16/19 at 9:55 A.M. with Resident #48 revealed he had severe pain in his back for the last two months, and he stated he felt the facility does not know how to treat his pain as some days it really hurts bad. Resident #48 was sitting on the side of his bed holding his lower back with a facial grimace when he went to lay back down. Interview on 09/18/19 at 9:53 A.M. with Registered Nurse/ Assistant Director of Nursing #605 revealed they completed pain assessments weekly to monitor a resident's pain and to ensure pain management was effective. She revealed the pain assessments were to look at interventions used and see if the interventions were effective. She verified the pain assessments completed for Resident #48 on 08/08/19, 08/16/19 and on 09/16/19 were not accurate as Resident #48 did receive as needed pain medication, he did receive non-medication interventions, and he did have pain. She revealed he complained almost daily of pain and received routine medication as well as needed pain medication almost daily due to pain. She verified his pain appeared to have increased since the last MDS dated [DATE] as his highest pain intensity recorded was a three on the MDS, and in August 2019 he had pain intensity levels of an eight out of ten, and September 2019 he had pain intensity levels of a seven out of ten. Review of the facility policy labeled, Pain Assessment and Management dated 03/31/16 revealed pain assessment and adequate treatment of pain was central to the management of the physical and psychological well-being of the residents. The resident's pain was to be assessed with the admission process and as needed thereafter. If a resident was alert and oriented, he was asked to describe his pain and obtain pertinent information regarding the pain. The resident's response to interventions was to be evaluated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Observation of a medication pass for Resident #72 on 9/17/19 at 8:38 A.M. by LPN #201 revealed the resident received a blood glucose check and sliding-scale insulin administration as part of the pass. Observation at this time revealed a breakfast tray containing no remaining food at the resident's bedside table. Interview with Resident #72 at the time of the above observation revealed he had already received his breakfast and eaten it before the nurse arrived for his blood glucose test. Interview with LPN #201 on 09/17/19 at 9:10 A.M. confirmed she gave Resident #72 his glucose test and insulin after he had already eaten breakfast. Record review of Resident #72 revealed he had a diagnosis of Type II Diabetes Mellitus. He had an order dated 01/08/19 for insulin to be administered based on the blood glucose value (sliding scale insulin) four times per day, before each meal and at bedtime. Based on observation, interview, record review and policy review, the facility failed to complete accu checks (use of a glucometer to test a resident's blood sugar level) and sliding scale insulin coverage before they received their meal in a timely fashion affecting four residents (Resident #56, #72, #92, and #100) of 19 residents receiving accu checks with insulin sliding scale coverage. This had the potential to affect 56 residents at the facility with a diagnosis of diabetes. Findings include: 1. Record review for Resident #56 revealed an admission date of 08/14/17 with diagnoses including diabetes mellitus, chronic kidney disease and diabetic neuropathy. Review of care plan dated 08/15/17 revealed Resident #56 was at risk for hypoglycemia and hyperglycemia episodes and required daily insulin related to diabetes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of hyperglycemia and hypoglycemia. Review of Resident #56's September 2019 physician orders revealed she had an order for a low concentrated sweets diet and Novolog 100 units per milliliter inject as per sliding scale subcutaneously three times a day for diabetes. Review of Medication Administration Record (MAR) for September 2019 revealed Resident #56 received her accu check which was 188 milligrams per deciliter (mg/dL) and she received Novolog two units subcutaneously per sliding scale coverage at 3:45 P.M. Interview on 09/18/19 at 5:50 P.M. with Licensed Practical Nurse (LPN) #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their glucometer checks and sliding scale at 4:00 P.M. She revealed she obtained Resident #56's accu check and administered her sliding scale insulin coverage at 3:45 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some arrived at the B unit at 5:56 P.M., and she verified it was over two hours from the time Resident #56 received her sliding scale insulin coverage until the time she received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #56's accu check and administered her insulin sliding scale coverage over two hours before Resident #56 received her tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed Novolog needed to be given within a half hour of Resident #56 receiving her meal as any longer could have the potential to cause a hypoglycemic reaction as Novolog was a fast-acting insulin. 2. Record review for Resident #110 revealed an admission date of 04/20/05 with diagnoses including diabetes mellitus, malignant neoplasm of left breast, mild intellectual disabilities and Parkinson's disease. Review of care plan dated 03/04/14 revealed Resident #110 was at risk for hypoglycemia and hyperglycemia episodes and required daily insulin related to diabetes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of hyperglycemia and hypoglycemia. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #110 had intact cognition and received insulin. Review of physician orders for September 2019 revealed Resident #110 had an order for Novolin Regular (R) insulin 100 units per milliliter inject per sliding scale subcutaneously before meals due to her diabetes. Review of MAR for September 2019 revealed Resident #110 on 09/18/19 at 4:16 P.M. received her accu check which was 188 mg/dL, and she was administered two units of Novolin R insulin per her sliding scale subcutaneously per LPN #600. Interview on 09/18/19 at 5:50 P.M. with LPN #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their accu checks and sliding scale at 4:00 P.M. She revealed she obtained Resident #110's accu check and administered her sliding scale insulin coverage at 4:16 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays arrived at the B unit at 5:56 P.M., and she verified it was over an hour from the time Resident #110 received her sliding scale insulin coverage until the time she received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #110's accu check and administered her sliding scale coverage over an hour before Resident #110 received her meal tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed Novolin Regular insulin needed to be given within a half hour of Resident #110 receiving her meal as any longer than a half hour could have the potential to cause a hypoglycemic reaction as Novolog was a fast-acting insulin. 3. Record review for Resident #92 revealed an admission date of 10/25/16 and diagnoses included diabetes mellitus with diabetic neuropathy, severe non-proliferative diabetic retinopathy with macular edema and dysphagia. Review of care plan dated 10/25/16 revealed Resident #92 was at risk for hypoglycemia and hyperglycemia episodes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of hyperglycemia and hypoglycemia. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #92 was cognitively intact and received insulin. Review of physician orders for September 2019 revealed Resident #92 had an order for low concentrated sweet diet and was to receive Novolog (insulin) 100 units per milliliter inject as per sliding scale subcutaneously before meals and at bedtime due to her diabetes. Review of Resident #92's MAR for 09/18/19 at 4:44 P.M. Resident #92's accu check was checked and was 164 mg/dL. She was given Novolog four units subcutaneously per her sliding scale coverage. Interview on 09/18/19 at 5:50 P.M. with LPN #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their accu checks and insulin sliding scale at 4:00 P.M. She revealed she obtained Resident #92's accu check and administered her sliding scale insulin coverage at 4:44 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays arrived on the B unit at 5:56 P.M., and she verified it was over an hour from the time Resident #92 received her sliding scale insulin coverage until the time Resident #92 received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #92's accu check and administered her sliding scale coverage over an hour before Resident #92 received her tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed Novolog needed to be given within a half hour of Resident #92 receiving her meal tray as any longer than a half hour before eating could have the potential to cause a hypoglycemic reaction as Novolog was a fast-acting insulin. Review of facility policy labeled, Care of the Adult Diabetes Mellitus Resident dated 02/21/2007 revealed the staff was to assist the resident to establish a balance between diet, exercise and insulin and was to prevent recurrence of hyperglycemia and hypoglycemia. The policy did not include timing of the administration of short acting insulin with the timing of when a resident received their meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not provide an adequate number of clinical nutrition staffing hours to address weight loss and implement nutritional interventions in a timely manner. This affected two (Resident #71 and Resident #119) of six residents reviewed for nutrition and had the potential to affect all residents in the facility. The facility census was 170. Findings include: 1. Record review was conducted for Resident #71 who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and trouble swallowing (oropharyngeal dysphagia). The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he was cognitively intact and required set up assistance by staff for meals. The Plan of Care with an initial date of 12/24/15 indicated he was at nutritional risk due to Parkinson's disease and swallowing problems. The interventions included monitoring weights and notifying the physician of any significant weight changes. The weights documented in the record were as followed: 02/12/19 - 162.0 pounds, 03/26/19 - 158.0 pounds, 04/16/19 - 155.8 pounds, 05/04/19 - 153.0 pounds, 06/10/19 -152.0 pounds, 07/04/19 - 151.0 pounds, 08/20/19 - 145.8 pounds and 09/07/19 143.4 pounds for a 10.0 percent significant weight loss from 02/12/19 to 08/20/19. On 12/19/15, a physician's order for a regular diet was written, and on 06/18/19 a physician's order was written to encourage 240 milliliters (ml) of fluid every shift due to dehydration risk. An interview and observation was conducted on 09/17/19 at 2:21 P.M. with Resident #71 in his room. He was left side lying across his bed with his lunch tray sitting on his bed side table next to his bed. When asked if he was having any problems eating, he reported his right hand (dominant hand) was hard to close, and that made it difficult to hold the utensils on his meal tray. He demonstrated trying to close his hand, and his fingers were not able to close enough to touch his palm. Resident #71 said he preferred to eat in his room and had just consumed most of his lunch with difficulty holding the fork. He appeared thin for his frame, spoke in a soft voice with somewhat garbled speech but was able to get his meaning and points across to the listener. Record review was conducted of the Dietary Assessment Narratives and Nutrition Assessments authored by Registered Dietetic Technician (RDT) #442 from 04/01/19 to 07/19/19. There were no further entries by RDT #442 after 07/19/19 addressing the dehydration risk or the documented weight declines recorded in the medical record through 09/07/19. The next entry by RDT #442 was after speaking to the state surveyor on 09/18/19. An interview was conducted with Dietary Manager (DM) #443 on 09/18/19 at 9:40 A.M. regarding who was responsible for addressing the nutritional needs and weights of the residents. DM #443 shared she obtained diet histories on the residents, and RDT #442 did all the nutritional assessments and follow up on the resident nutritional needs. DM #443 added Registered Dietitian (RD) #700 visited one to two days a month and would complete sanitation rounds in the kitchen on one of those days. Record review was conducted of the facility document titled Facility Assessment, dated 2019 to 2020. The document failed to identify the staffing needs for dietary and clinical nutrition services personnel in the facility to meet the acuity needs of the residents. An interview was conducted on 09/18/19 at 10:37 A.M. with the Administrator who verified there was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few no staffing plan on the current facility assessment to identify the number of dietary staff needed to carry out the daily function of kitchen services and clinical nutrition assessments and follow-up on the residents needs. An interview was conducted on 09/18/19 at 11:55 A.M. with RDT #442 with the Director of Nursing (DON) present during the interview. RDT #442 verified he had not addressed Resident #71's significant weight change, did not put any interventions in place to address the weight change nor was the physician notified of the weight change. He verified he had a case load of 170 residents and was the only clinical nutritionist for the facility and must have somehow missed addressing the weight on 08/20/19. When asked if he had any Registered Dietitian (RD) oversight, he shared a corporate RD comes to the facility one to two times a month or to cover his vacations, but besides that he is responsible for the case load of 170 residents on his own. The DON also verified the physician was not notified of the weight change, and she was working on a better system to keep track of the weight changes in the facility. Record review was conducted of the facility document titled Weight Change Protocol, dated 07/01/2004. The document stated resident weights would be reviewed weekly to identify those residents who were experiencing weight changes. 2. Review of the medical record for Resident #119 revealed an admission date of 02/18/13. Diagnoses included cerebral infarction, dysphagia, hemiplegia and hemiparesis, anorexia nervosa, vascular dementia and adult failure to thrive. Review of the quarterly MDS 3.0 assessment, dated 08/10/2019, revealed the resident had impaired cognition. The resident had delusions and physical behavior directed at others. Resident #119 required limited assistance for eating. The resident was on hospice. Review of physician orders for 09/2019 identified orders for a regular diet, pureed texture, nectar thick liquids. Review of the dietary progress note dated 08/07/19 at 9:04 A.M. revealed Resident #119 was receiving hospice services. On 07/04/19, the resident weighed 142.2 pounds and had a Body Mass Index (BMI) of 19.8 indicating underweight status for age and a height of 71 inches. There were no significant weight changes at one, three or six months; however, a gradual weight loss of 11.4 pounds was noted. Resident received assistance with feeding in the dining room and consumed 25 to 75 percent of meals on the pureed diet with nectar thickened liquids. Meal intakes were not meeting estimated daily nutrient needs. The resident was at high risk for nutritional decline per the nutrition risk tool. No new recommendations were made. The plan was to continue with current diet regimen. Review of the dietary progress note dated 09/06/19 at 10:20 A.M. revealed Resident #119 was no longer receiving hospice services. No new weight had been obtained from the previous dietary progress note. The resident was assisted with feeding and was consuming 25 to 100 percent of meals on the pureed diet with nectar thickened liquids and tolerating well. The plan was to continue with the current diet regimen. Review of supplement documentation revealed no supplements were provided. Review of weights revealed on 09/10/19 Resident #119 weighed 138 pounds. On 06/21/19 the resident weighed 141.8 pounds. On 01/08/19 the resident weighed 153.6 pounds. Resident #119 had a weight loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 of 2.75 percent in three months, 4.35 percent in six months and 11.3 percent in eight months. Level of Harm - Minimal harm or potential for actual harm Interviews on 09/18/19 at 10:41 A.M. RDT #442 verified Resident #119 was not receiving a supplement, and no interventions had been made even though the dietary progress notes indicated meal intakes were not meeting estimated daily nutrient needs, the resident was at high risk for nutritional decline per the nutrition risk tool and there had been a gradual weight loss. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility did not ensure food was served at palatable temperatures to Residents #75, #149, #161 and #469. This affected four of seven residents reviewed for food. The facility census was 170. Residents Affected - Some Findings included: Interview was conducted on 09/16/19 at 12:07 P.M. with Resident #469 who revealed he ate in his room, and the hot food was never hot. He explained the problem was at lunch and dinner time, any food he was served that should be hot was barely warm in his mouth. Interview was conducted on 09/16/19 at 12:12 P.M. with Resident #75 who revealed he ate in his room and he was almost never served a hot meal. He gave examples of hamburgers, casseroles, soups and hot sandwiches were barely warm by the time he was served in his room. Interview was conducted on 09/16/19 at 12:22 P.M. with Resident #149 who stressed he would be happy if he could get a hot meal once in a while. Resident #149 shared he preferred to eat in his room, and he would have to ask for his meal to be reheated if he wanted to eat hot food. Interview was conducted on 09/16/19 at 12:44 P.M. with Resident #161 who revealed the food was not served hot, and he preferred to eat in his room. He gave examples of potato, roasts and sandwiches that should be hot but were served just warm. An observation was conducted on 09/18/19 from 4:20 P.M. to 6:07 P.M. with Dietary Manager (DM) #443 of dinner tray line and a room test tray. At 4:20 P.M., [NAME] #444 took tray line temperatures as followed: baked potato - 179 degrees Fahrenheit (F), steamed broccoli - 168 degrees F, chili sauce - 171 degrees F, and cheese sauce 163 degrees F. Next to the tray line sat large tub containers filled with ice and contained half pints of white milk and tulip dishes with fresh, green melon. [NAME] #444 finished the temperatures at 4:24 P.M., and no additional food temperatures were taken during the course of the tray line during the observation. Tray line service started at 4:50 P.M. with [NAME] #445 serving the meal to the main dining room just off the kitchen. At 5:15 P.M., [NAME] #445 began serving the trays that were going to be transported to the secured unit dining room. At 5:34 P.M., [NAME] #445 began serving the room trays for the B unit hallway cart. At 5:55 P.M., a test tray was placed lastly onto the B unit hallway cart. At 5:56 P.M., the cart was on the B unit. All trays were passed by 6:07 P.M., and the test tray was removed from the cart to begin obtaining food temperatures. DM #443 began taking the temperature of the half pint of milk using a calibrated, digital touch-point thermometer. At 6:07 P.M., the milk was 47.8 degrees F. The remaining temperatures were taken as followed: baked potato with chili and cheese sauce - 119.6 degrees F, steamed broccoli - 107.0 degrees F and fresh melon - 50.4 degrees F. The baked potato item and steamed broccoli felt barely warm in the mouth of the surveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carington Park 2217 West Ave Ashtabula, OH 44004 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manor. This had the potential to affect the 167 residents receiving food prepared in the kitchen. Three residents did not receive food from the kitchen (Resident #114, Resident #122 and Resident #45). The census was 170. Findings include: On 09/16/19 at 9:41 A.M., during the initial tour of the kitchen, observation of the shelf over the stove revealed it was greasy and dusty. There were two pans, open side facing upward, set on top of the dirty surface. On 09/16/19 at 9:52 A.M this was verified by Dietary Manager #444. The pans were removed and rewashed, and the shelf was washed. On 09/18/19 at 4:40 P.M. observation of the kitchen ceiling directly over tray line revealed there were three air vents on the ceiling measuring approximately two feet by two feet surrounded by rectangular ceiling tiles measuring approximately 16 inches by 36 inches in size. Three of those ceiling tiles hung directly over tray line holding open pans of food, and the tiles were heavily covered in black dust. Some of the dust was blowing in the air currant coming from the vents. On 09/18/19 at 4:45 P.M. this was reviewed with and verified by Dietary Manager #444. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365286 If continuation sheet Page 19 of 19